Lowering readmits through transitional care

Discharge, readmit, discharge, readmit. It’s the healthcare cycle many seniors are trapped in as they age and/or their disease process runs its course—a discouraging and costly cycle. However, it has been found that participating in transitional care programming whether at home or in a post-acute facility is effective at breaking that cycle.

This week, the Archives of Internal Medicine featured the results of two studies that investigated and measured the success of transitional programming. One study examined the results after a transition coach followed a patient through hospital and home visits and two follow-up phone calls. Researchers found that the readmission rates were significantly lower at 12.8 percent than for those patients that were discharged without coaching support. According to the authors, “This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.”

Patients with heart failure were the focus of another study conducted at Baylor Medical Center Garland, part of Baylor Health Care System. The authors concluded that a transitional care intervention led by an advanced practice nurse, which included a minimum of eight post-discharge calls, cut readmissions of senior patients with heart failure by 48 percent. However, the authors note that this intervention can be effective in a real-world setting but, “payment reform may be required for the intervention to be financially sustainable by hospitals.”

Focusing on reducing instances of readmission, the cardiac rehab unit of ManorCare—Rocky River (Ohio), is a midpoint between hospital and home for rehabilitating and educating its cardiac patients.